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Inflammatory abdominal aortic aneurysms
Abstract
The authors present a review of the literature on inflammatory abdominal aortic aneurysms. These aneurysms represent from 3 to 10% of all abdominal aortic aneurysms. Progress has occurred in the technical approach to these aneurysms, and operative morbidity and mortality have been remarkably reduced. However, the pathogenesis remains poorly understood. Early reports have considered the inflammatory aneurysm as a distinct clinical and pathological entity, whereas recent evidences suggest a common etiopathogenetic mechanism for both atherosclerotic and inflammatory aneurysms. Finally, genetic and environmental factors, such as tobacco use, may predispose certain persons to the development of non-inflammatory aneurysms and others to a wide spectrum of inflammatory reactions until inflammatory aneurysms development. The most common clinical features of these aneurysms are represented by symptoms, such as abdominal or back pain, obstructive uropathy and by an elevated erythrocyte sedimentation rate. Computed tomography (CT) allows a specific diagnosis by the typical image of soft tissue surrounding the aortic wall enhancing with contrast administration. Ultrasonography is less sensitive whereas nuclear magnetic resonance (RNM) is a promising technique. Excretory urography may suggest the diagnosis by demonstration of ureter entrapment. Surgical therapy, by a technique of limited dissection represents the definitive treatment. Evolution of fibrosis after surgery is still debated because some studies have reported complete regression of inflammation and other partial regression or persistence of fibrotic process. At present, endovascular treatment of these aneurysms is occasionally reported, although preliminary results appear satisfactory.
... The entity they described was an aneurysm characterized by " an unusually thick wall surrounded by extensive fibrous adhesions, involving adjoining tissues and structures. " The reported incidence of inflammatory aortic aneurysms in the literature varies between 2.5% and 15% of all AAA12345678910111213141516. The distinct clinicopathologic findings (symptomatology as described below, together with the triad of a thickened aneurysmal wall, extensive peri-aneurysmal and retroperitoneal fibrosis, with adhesions to adjacent abdominal organs) led to the view that inflammatory AAA was a separate clinical entity12345678. ...
... However, the absence of hemosiderin-laden macrophages in the peri-aneurysmal tissue, expected to be found in the case of blood extravasation, has refuted this theory [1,4,5,11]. Although an infectious causation has been considered, bacterial cultures of the aneurysm wall have consistently been negative, as have serologic tests for syphilis [1,4,5,16]. Of interest in this regard is the finding by Tanaka and colleagues [17] that the herpes simplex virus or cytomegalovirus was more frequently present in the wall of aneurysms than in the normal aortic wall. ...
... In fact, the triad of abdominal or back pain, weight loss, and elevated erythrocyte sedimentation rate in patients with AAA is highly suggestive of the inflammatory variant [6,8,11,14]. These aneurysms also tend to be larger than the atherosclerotic type [8,9,11,14,16]. Entrapment of the duodenum (100%) and ureters (53%) in the retroperitoneal fibrotic process is frequently observed [3,9]. Obstructive uropathy has previously been described as a presenting manifestation of inflammatory AAA and is found in about 21% of patients1239]. ...
... Aortitis, characterized by inflammation of the aortic wall [5], is an uncommon cause of aortic aneurysm with inflammatory aneurysms compromising only 3 to 10% of abdominal aortic aneurysms [6]. The most common causes of aortitis include the large vessel vasculitis, giant cell arteritis, and Takayasu arteritis. ...
Primary aortoenteric fistula is a rare cause of upper gastrointestinal bleed but can lead to significant mortality if the diagnosis is delayed. Aortitis, characterized by inflammation of the aortic wall, is a rare cause of aortoenteric fistula. We present a case report of a 72-year-old male patient with infectious aortoenteric fistula secondary to Streptococcus parasanguinis , along with a review of the literature. This case demonstrates the importance of early diagnosis and aggressive surgical treatment of aortoenteric fistulae and recognizing infectious aortitis as a potential etiology.
... Often surgical treatment is inadequate to control retroperitorenal fibrosis and so the surgeon has to use perioperating pharmacolocical therapy and/or ureteral stenting. Despite the similarity of Infected and Inflammatory AAA, the infected one generally shows a more rapid change in clinical condition, leading to a fatal outcome; in addition, delayed diagnosis and misuse of corticosteroid or immunosuppressing drugs may lead to uncontrolled growth of microorganisms (4,5). It is mandatory that detection of aortic aneurysm is followed by accurate differential diagnosis among aortic aneurysm, infected and inflammatory aortic aneurysm. ...
We report a case of Inflammatory Abdominal Aortic Aneurysm (IAAA) producing bilateral hydro-ureteronephrosis. A 74-year-old patient presented to urologist office for bilateral hydronephrosis detected by kidney and bladder ultrasound (US). Patient reported lower urinary tract symptoms and inconstant and slight low back pain irradiated to inguinal region dating 3 weeks. Renal function, urine analysis and abdominal examination were normal. However the repeated ultrasound in the urologist office revealed abdominal aortic aneurism extended to iliac vessels. The patient was sent directly to vascular surgery unit where contrast computerized tomography (CT) and successful surgical repair were done. Final diagnosis was IAAA. The post-operative course was uneventful. Renal function was regular and the hydronephrosis reduced spontaneously under monitoring by CT and US. We review diagnosis and management of hydronephrosis that is sometimes linked to IAAA rather than standard AAA. Abdominal ultrasound is mandatory in any bilateral hydronephrosis and it could save lives.
... As the disease progresses, the inflammation will worsen in the arterial wall, and thrombosis and vessel rupture may occur. 23 Although other inflammatory cells such as T and B cells were seen in the tissue samples of AAAs and might play roles in AAAs, 24 infiltration and accumulation of macrophages was very prominent in the development of AAAs. Because of the scarcity of human samples of AAAs in the early stages, data showing the macrophage infiltration into human arterial wall were mostly from the biopsy specimens of AAAs at late stages. ...
Objective:
This study examined the influence of 3,4-benzopyrene (BaP), a compound found in cigarette smoke, on the formation of angiotensin II (Ang II)-induced abdominal aortic aneurysm (AAA) formation in mice and the underlying mechanisms.
Methods:
C57/B6n mice were divided into four groups. The control group received a weekly intraperitoneal injection of medium-chain triglycerides. The Ang II group received a daily Ang II infusion (0.72 mg/kg) and a weekly intraperitoneal injection of medium-chain triglycerides. The Ang II/BaP group received a daily Ang II infusion (0.72 mg/kg) and a weekly intraperitoneal BaP injection (10 mg/kg, dissolved in medium-chain triglycerides). The BaP group received a weekly intraperitoneal BaP injection (10 mg/kg). After 5 weeks, abdominal aortic diameter was determined. Aortic tissues underwent hematoxylin and eosin, Masson, and immunochemistry staining for evaluation of vascular wall structure, collagen, macrophage infiltration, matrix metalloproteinases (MMPs), and apoptosis.
Results:
The Ang II infusion and BaP injection induced AAAs in 41.67% of mice vs 25% in the Ang II group (P < .05). The average aortic diameter increased in the Ang II/BaP group compared with the Ang II group (1.40 ± 0.25 vs 1.2 ± 0.23 mm; P < .05). Average aortic muscular cell apoptosis was higher in the Ang II/BaP group (31% ± 12%) than in the Ang II (19% ± 5%; P < .05) or BaP groups (23% ± 4%; P < .05). Aortic macrophage infiltration and expression of MMP-2, MMP-9, MMP-12, and nuclear factor-κB increased (0.56 ± 0.12, 0.47 ± 0.13, 0.49 ± 0.14, 0.49 ± 0.11, and 0.42 ± 0.12, respectively) in the Ang II/BaP group compared with the Ang II group (0.27 ± 0.08, 0.25 ± 0.06, 0.24 ± 0.09, 0.24 ± 0.09, and 0.23 ± 0.06, respectively; P < .05 for all).
Conclusions:
BaP promotes Ang II-induced AAA formation in mice via elevating infiltration of macrophages, activating nuclear factor-κB, upregulating the expression of MMP-2, MMP-9, and MMP-12, and increasing the apoptosis of vascular muscle cells in its synergistic effect with Ang II in aortic wall.
... Among the many components of cigarette smoke, BaP causes unique biological effects consistent with the vascular pathology seen in individuals who smoke (Ramos et al 2007). The pathological process of AAA was characterized by infi ltration and accumulation of macrophages in the arterial wall (Rubini et al 2001; Forester et al 2005), disruption of elastic lamella and deterioration of collagen networks (Thompson and Parks 1996; Daugherty and Cassis 2002), and loss of VSMC in the media (Lopez-Candales et al 1997; Thompson et al 1997)Figure 1 High incidence of AAA formation in C57/B6J mice treated with both AngII and BaP. Representative HE-stained tissue sections of suprarenal segments (1 cm above left renal artery) of the aortas from control and treated mice were shown (A). ...
Cigarette smoking has been strongly associated with abdominal aortic aneurysm (AAA), but the components of tobacco smoke involved in AAA have not been identified. Benzo(a)pyrene (BaP) is an important constituent in cigarette smoke capable of induction of alterations strikingly similar to the pathological changes seen during AAA development. We therefore hypothesized that BaP exposure contributes to the development of AAA. In this study, C57/B6J mice were treated with vehicle, angiotensin II (AngII) (0.72 mg/kg/day), BaP (10 mg/kg/week), or the combination of AngII and BaP, for 5 weeks, and then examined for incidence of AAA and pathological changes of the aortic wall. Results showed that incidence of AAA formation in C57/B6J mice treated with BaP and AngII was significantly higher than that in AngII-treated mice (7 of 12 compared to 2 of 12). Further, five mice in the group treated with AngII/BaP and one in the group treated with AngII exhibited AAA rupture and hematoma. BaP caused macrophage infiltration, disarray of elastic lamella, and loss of vascular smooth muscle cells (VSMCs). We conclude that BaP aggravates AAA formation and rupture in C57/B6J mice by promoting macrophage infiltration, degeneration of elastic lamella, and loss of VSMCs in the aortic wall.
The severity of aneurysmatic disease and its evolution were already described long ago. Since that time, the therapeutic strategies have been based on surgical procedures, which have been modified according to scientific and technical developments in the medical fields. The Papyrus of Erbes, written in approximately 2,000 B.C., described peripheral aneurysms and suggested surgical treatment with a glowing iron: “treat with the knife and burn with fire …” [1,2].
Inflammatory abdominal aortic aneurysms (IAAA) represent 3% to 10% of all abdominal aortic aneurysms. Obstructive uropathy is a well-described feature of IAAAs, but venous complications are unusual secondary to IAAA. The authors report a patient presenting with acute renal failure and deep venous thrombosis secondary to an IAAA. We believe this represents the first case of an IAAA manifesting as combined inferior vena cava compression and associated obstructive uropathy. Successful operative repair was performed. With resolution of the retroperitoneal inflammation, long-term follow-up revealed spontaneous release of both ureteral and caval compression.
The inflammatory variant of aortic aneurysms has 3 unique features: marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and rigid adherence of the adjacent structures to the anterior aneurysm wall. Abdominal tenderness with or without a pulsatile abdominal mass is the most common finding, although it is present in only about 33% of patients. Systemic symptoms, such as fever, malaise, and weight loss, are reported in about 20% to 50% of patients. A contrast-enhanced computed tomography scan, magnetic resonance imaging, and a transesophageal echocardiogram are among the best modalities to evaluate for inflammatory thoracoabdominal aneurysm, but a transthoracic echocardiogram can frequently be very suggestive. Medical treatment options include corticosteroids or other anti-inflammatory and immunosuppressive therapies. Surgical intervention usually consists of a transperitoneal approach with infrarenal aortic clamping. This case review describes a 64-year-old woman with a history of hypertension and dyslipidemia who presented with anemia, lower back pain, and a recent 30-pound weight loss.
Operative morbidity and mortality are elevated in patients with inflammatory abdominal aortic aneurysm. Preoperative identification of inflammatory abdominal aortic aneurysm. the detection of the proximal level and of adhesions to adjacent structures are important for surgical management. The sensitivity and specificity of ultrasonography and computed tomography (CT) for identification and staging in 13 patients with inflammatory abdominal aortic aneurysm were studied. Preoperative radiological diagnoses were validated by intraoperative findings. Correct identification of inflammatory abdominal aortic aneurysm could be achieved in 85% by the use of CT and in 62% by ultrasonography. The proximal level of inflammatory abdominal aortic aneurysm was correctly determined by CT in all patients and by ultrasonography in 62%. Using a transperitoneal approach, the condition was considered inoperable in two patients as a result of the suprarenal extent of the aneurysm and because of unremovable adhesions in two other cases. In the latter pair, it was impossible to predict inoperability by radiological findings. Sensitivity (85%) and specificity (100%) of standard radiological techniques to identify inflammatory changes are high. Inoperability caused by suprarenal extent could be detected correctly by routine radiological procedures. However, identification of dense adhesions appears uncertain.
Inflammatory aortic aneurysms are distinct clinical entities seen mostly in the infrarenal abdominal aorta and rarely in the descending thoracic aorta. We present the case of a 61-year-old woman with an inflammatory aortic aneurysm of the ascending aorta and aortic arch.
Peri-aneurysmal fibrosis complicating inflammatory aneurysm of the abdominal aorta may involve the ureters, causing urological complications. We assessed patient anatomical and clinical outcomes after conservative ureteral management.
From the operative records of 1,271 consecutive patients who underwent surgical repair of abdominal aortic aneurysms from 1980 to 1999 we identified 77 (6%) who had inflammatory aneurysms, which were complicated in 19 (24.6%) by dense peri-aneurysmal and ureteral fibrosis. Of these 19 patients 15 (78.9%) had coexisting monolateral hydronephrosis, 3 (15.7%) had bilateral hydronephrosis and 1 (5.2%) had renal atrophy. In 14 cases (73.6%) the fibrotic reaction severely impaired renal function. Only 1 patient underwent an emergency operation, while the others underwent elective repair. Only 2 patients (10.5%) underwent a specific urological procedure, including bilateral nephrostomy in 1 and ureterolysis plus ureterolithotomy in 1. Most ureteral complications were treated conservatively by aneurysmectomy only.
Immediate postoperative mortality was 7% (1 of 14 cases). Median followup was 48 months. In 1 of the 13 cases (7.7%) a ureteral stent was placed during followup. After aneurysmectomy in 9 of the 12 patients (75%) with renal dysfunction periaortic fibrosis disappeared or decreased as well as associated hydronephrosis. In 11 of the remaining 12 patients (91%) of the 14 with renal failure preoperatively kidney function returned to normal or improved. In the 2 patients who underwent a specific urological procedure renal function improved but did not return to normal.
Inflammatory abdominal aortic aneurysms involving the ureters and compressing the urinary structures respond well to aneurysmal resection only without a urological procedure.
To study the technical feasibility and results of endovascular treatment of inflammatory abdominal aortic aneurysms (AAA).
Prospective study.
Seven patients underwent endovascular repair of an inflammatory AAA. Five patients (8 ureters) were treated with ureteric stents CT scans were obtained one year.
The early technical success rate was 100%. Four ureters remained entrapped at one year. Partial regression of periaortic fibrosis was documented in three patients, while four patients showed no regression.
Endovascular reconstruction of inflammatory abdominal aneurysms is technically feasible. Further study is warranted with regard to the evolution of the periaortic fibrosis and the possible benefits for patients with concomitant hydronephrosis.
It has been suggested that certain genetic risk factors indicative of an autoimmune mechanism can be identified in patients with inflammatory aortic aneurysm (IAA). We therefore investigated whether there was a higher incidence of autoimmune diseases in patients with IAA. Further, we explored risk factors, need for in-hospital resources, and early results of treatment, in a case-control study in a university hospital setting. Material and methods From 1983 to 1994, 520 patients were operated because of abdominal aortic aneurysm (AAA). Thirty-one patients had IAA. Control subjects were matched for aneurysm rupture, emergency or elective hospital admission, and date of operation. Two noninflammatory AAA were included for every IAA.
Of the 31 patients with IAA, 6 patients (19%) had autoimmune disease, compared with none of the control subjects (P =.0017). Two patients had rheumatoid arthritis, 2 patients had systemic lupus erythematosus, 1 had giant cell arteritis, and 1 patient had an undifferentiated seronegative polyarthritis diagnosed as rheumatoid arthritis. Nineteen patients (61%) with IAA had involvement of the duodenum, and 8 patients (26%) had hydronephrosis with ureteral involvement. Operating time was longer in the IAA group, which also had a higher need for blood transfusion. Hospital stay, intensive care unit stay, and 30-day mortality were similar in the two groups.
Except for longer operating time and more need for blood transfusions in the IAA group, use of hospital resources was similar after operations to treat IAA or noninflammatory AAA. The study findings indicate an association between IAA and autoimmune disease. This is in accordance with other reports that showed a genetic risk determinant mapped to the human leukocyte antigen (HLA) molecule in these patients. Further research is necessary to explore whether IAA might be a separate entity with a role of antigen binding in the origin of the disease.
Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment.
Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay.
Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy.
Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.
The incidence of inflammatory abdominal aortic aneurysm (IAAA) in a late review of the literature is estimated about 2-15% overall aortic aneurysms. In our data this type of aneurysm is 3.6 overall aortic aneurysms treated. In the majority of the cases, IAAA is juxtarenal or infrarenal. Ethiopathogenesis of IAAA till today is not certain. Recent hypothesis on IAAA attribute the same ethiopathogenesis in both atherosclerotic and inflammatory aneurysm. The interaction of genetic, environmental and infective factors should be able to determine an autoimmune inflammatory reaction of variable severity. 80% of the patients suffering from IAAA present abdominal or lumbar pain, loss of weight and increase of the RC sedimentation velocity. The IAAA's natural history goes to rupture. Entrapment of nearstanding organs totally involved in the fibrotic process is the most frequent complication. Usually there is a compression of the ureter and the duodenum with consequenced hydroureteronephrosis and bowel obstruction. Preoperative diagnosis is possible; CT scan and MRI guarantee and accuracy about 90%. Intraoperatively the external wall of IAAA appears whitish and translucent and always there are tenacious adhesion given by the avventital wounds inflammation. Confirm is given by the histological examination of the aneurysmatic wall and peravventitial tissues. Our experience and a late review of the literature concorde that surgical indication for the treatment of IAAA is the same for the atherosclerotic one. This conviction is supported by the fact that the diagnostic methodical evolution and the improvement in mininvasive surgical technique lowered perioperating morbility and mortaliy. We prefer, according with many authors, retroperitoneal approach to juxtarenal IAAA, instead of standardized transperitoneal access with xifo-pubical or transversal under costal incision. This approach offers some advantages as easier exposition of aorta, whose postero-lateral wall is hardly ever involved in inflammatory process, little duodenum's and left renal veins manipulation and low incidence of paralytic ileum and respiratory disease. Endovascular surgery hasn't in this moment any role in juxtarenal IAAA treatment because this type of aneurysm has inadequate proximal neck. In the future, probably, endovascular repair will be possible using a new type of endograft with renal legs. Often surgical treatment is inadequate to control retroperitorenal fibrosis and so surgeon has to use perioperating pharmacolocical therapy.
A total of 274 patients with abdominal aortic aneurysms due to atherosclerosis (AAA) and 16 patients with inflammatory abdominal aortic aneurysms (IAAA) were reviewed to compare and contrast the clinical characteristics of the 2 groups. The AAA group comprised 243 men and 31 women with a mean age of 69.2±0.4 (range 51-86) years. The IAAA group comprised 15 men and 1 woman with a mean age of 67.4±2.0 (range 53-81) years. Most patients with IAAA (12/16; 75.0%) had pain at presentation, whereas only 37 out of 274 patients (13.5%) with AAA had pain (p<0.001). Fifty out of 274 patients (18.2%) with AAA were asymp-tomatic, the most common principal complaint being a pulsatile tumor, which was found in 150 out of 274 patients (54.7%; p<0.005 vs IAAA). Regarding laboratory findings of inflammation, preoperative erythrocyte sedimentation rate values were elevated in 15 out of 16 (93.8%) patients, and C-reactive protein values were elevated in 13 out of 16 (81.3%) patients with IAAA. The incidence of perioperative complications was similar in the 2 groups. The 30-day postoperative mortality among AAA patients was 6.2% (17/274 cases), including 12 cases of non-ruptured and 5 cases of ruptured AAA; in contrast, no early deaths occurred among patients with IAAA. The cumulative 5-year survival rate was 80.2% for IAAA patients and 74.6% for AAA patients (NS). The results of our review suggest that careful diagnosis and intra- and postoperative management could lead to patients with IAAA having a similar survival rate to those with AAA. (Jpn Circ J 1997; 61: 231 - 235)
Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed.
Until changes of ureteric or vascular compromise are noted, retroperitoneal fibrosis usually goes unnoticed. When symptomatic retroperitoneal fibrosis has been associated with abdominal aortic aneurysm, ureteral involvement has uniformly been present. Three cases demonstrate a new ultrasonographic picture that can aid in early identification of retroperitoneal fibrosis before complications are manifest. In patients with abdominal aortic aneurysms, routine sonography may identify unsuspected retroperitoneal fibrosis, a factor that may be important in preoperative planning for safe surgical intervention.
This report reviews the authors' experience in diagnosing and managing 17 consecutive patients with inflammatory abdominal aortic aneurysm (AAA). Among 491 patients undergoing repair for AAA during a 10-year period, 17 (3%) had evidence of associated periaortic fibrosis, which was confirmed histologically. No patient had acute rupture, and two patients (12%) had chronic contained rupture. Ureteral obstruction was evident in seven patients. In 41% of the patients, available surgical correlation demonstrated that computed tomographic (CT) scan accurately delineated the extent of the disease. Sixteen patients underwent aneurysm resection. Ureteral obstruction was relieved by ureterolysis in three patients treated early in this series. In the last period of the study, well-documented hydronephrosis spontaneously subsided in two patients without special treatment. Of these 17 patients, 15 (88%) were early (30-day) survivors. There were two late deaths at 2 months and 5 years; 12 (71%) patients are still alive and free of symptoms up to 10 years after operation. On the basis of our study, we conclude the following: (1) precise preoperative diagnosis and detailed anatomic information are widely available with CT; (2) aneurysm resection is the treatment of choice because the risk of rupture still exists, and this procedure seems to reverse the inflammatory process; (3) good early and late results can be expected with proper surgical technique; and (4) routine follow-up with CT is recommended to document resolution or progression of the fibrotic process after aneurysm resection.
Inflammatory abdominal aortic aneurysms are characterized by dense perianeurysmal fibrosis involving the adjacent organs. Attempts to isolate the aneurysm can lead to operative injuries of these structures, thus increasing the rates of complications and mortality. In the last 12 years 45 patients with inflammatory abdominal aortic aneurysms underwent aneurysm resection at the Department of Vascular Surgery of the University of Rome. The aneurysm was resected through a standard, midline transperitoneal approach in 39 patients, through a thoracophrenolaparotomy in two patients, and through a left-flank extraperitoneal approach in the last four patients. The extraperitoneal approach simplified aneurysm dissection and aortic clamping with no cases of postoperative morbidity or death. In addition, we reviewed the CT scan findings of 12 patients surgically treated for inflammatory abdominal aortic aneurysm. The amount of fibrosis in the anterior wall of the aneurysm was greater than in the left posterolateral aspect (p = 0.008). We conclude that the left-flank extraperitoneal approach is the most anatomically advantageous route for repair of inflammatory abdominal aortic aneurysm.
Up to 15% of abdominal aortic aneurysms are designated as inflammatory. They are characterized by marked fibrous thickening of the aneurysmal wall, with the fibrosis extending into the adjacent retroperitoneum. Thirty-five abdominal aortic aneurysms were studied, 15 inflammatory and 20 atherosclerotic. Of the inflammatory group, 10 were symptomatic and five asymptomatic. For each resection specimen, 59 microscopic features (variables) were scored semi-quantitatively. Discriminant function analysis showed that endarteritis obliterans, fibrosis around nerves or ganglia at the outer margin of mural fibrosis, and the thickness of the combined fibrotic media and adventitia gave a satisfactory high discrimination between atherosclerotic and inflammatory aneurysms. When these three variables are used together, a histological diagnosis of inflammatory aneurysm can be made with an expected accuracy in excess of 80%.
Of a total of 780 patients with abdominal aortic aneurysms, 37 patients (4.7%) had inflammatory aneurysms. Presenting symptoms included back and abdominal pain (76%), leg edema, melena, uremia, claudication and pancreatitis. Mean erythrocyte sedimentation rate was 45 mm/hr. Weight loss and anorexia were common. Elevated urea and creatinine were seen on 11 patients, nine of whom had obstructive uropathy. Average aneurysm size was 9.3 cm. Thirty-six patients were treated surgically and one was observed. Involvement of the suprarenal (nine cases) or thoracic (three cases) aorta was common. Elective operations included resection and grafting in 21 patients and axillofemoral bypass in four patients. Patients with ureteral entrapment underwent simultaneous ureterolysis. Among the elective operations four deaths were noted (15%). Ten emergency operations were done for posterior rupture (four cases), aortoduodenal fistula (one case), inferior vena cava obstruction or fistula (two cases), hemorrhage into the aneurysmal wall (two cases), or presumed rupture (one case). There were seven deaths (70%) in this group. The operation of choice for inflammatory aneurysm is a bifurcation graft combined with ureterolysis.
The term 'inflammatory aneurysm' is used to describe a variant of atherosclerotic abdominal aortic aneurysms in which the wall of the aneurysm is unusually thick and surrounded by extensive fibrosis and adhesions. Repair of these aneurysms is associated with a higher mortality and morbidity than repair of those which are non-inflammatory, so that diagnosis prior to surgery is desirable. The use of computed tomography (CT) and ultrasound in this differentiation is discussed. The correct diagnosis was made in 16 out of 17 by CT, but in only three of nine cases who had ultrasound scans.
Some of the pitfalls in the management of inflammatory abdominal aortic aneurysm are stressed in the presentation of six illustrative cases. Background data on the presumed etiology and common symptoms are provided. The diagnostic value of computed tomography for preoperative detection of the fibrosis surrounding these aneurysms and the differentiation from other conditions are also discussed.
Inflammatory aneurysms represent a distinct surgical entity with a reported incidence varying from 5% to 23% of all abdominal aortic aneurysms. Surgical repair of inflammatory aneurysms is associated with a higher morbidity and mortality than is repair of simple aortic aneurysms. Complicated cases require suprarenal aortic control, and the surgeon must be forewarned to maximize the chance for successful aneurysm repair. Preoperative diagnosis of this entity by cross-sectional imaging facilitates improved planning of the operative approach and permits the institution of preoperative steroid treatment to reduce the volume of the periaortic fibrotic mass. Ultrasound demonstrates the inflammatory process as a hypoechoic mass surrounding the intensely echogenic, thickened aortic wall. Computed tomography reveals a thickened, often calcified aortic wall and a mass of periaortic inflammatory tissue. Dynamic scanning reveals rapid intraluminal enhancement, slightly delayed enhancement of the inflammatory mass, and nonenhancement of the thick fibrous adventitia.
Aortic aneurysmal disease appears to be the central focus of the inflammatory process resulting in inflammatory aneurysm formation. Some authors believe that inflammatory aortic aneurysm disease is a distinct clinicopathologic entity; however, others have included it with retroperitoneal fibrosis. The histologic features of inflammatory aneurysm suggest an immunologic basis for the lesion, with the atherosclerotic aorta as a possible source of the allergen.
Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.
The inflammatory abdominal aortic aneurysm has received little attention in the literature. To date only four reports have addressed the subject specifically. Controversy remains as to whether this is a variant of the usual atherosclerotic aneurysm or a separate entity. The operative reports of 24 patients with inflammatory abdominal aortic aneurysms are reviewed; 21 were intact and 3 ruptured. Intact aneurysms ranged in diameter from 5 to 12 cm and the ruptured ones from 5 to 10 cm. Nine patients with intact aneurysms had symptoms of abdominal or back pain. Of 13 patients who underwent excretory pyelography before operation, only 3 had evidence of obstruction. Nine patients had tube grafts placed, 10 had aortoiliac grafts and 5 aortofemoral grafts. There was one intraoperative duodenal injury and in another patient it was necessary to divide the left renal vein for proximal exposure. No attempt was made to expose the ureters at operation. All patients were discharged from hospital. The authors believe that the inflammatory aneurysm is a variant of the abdominal aortic arteriosclerotic aneurysm. Intraoperative complications can be avoided by the recognition of the pathological features.
The 14th case of ureteral obstruction secondary to an abdominal aortic aneurysm with perianeurysmatic fibrosis is discussed. The patient complained about attacks of pain in the left flank. Within a short time a leftsided hydronephrosis with compression of the ureter developed. Complete recovery was achieved by resection of the abdominal aortic aneurysm, combined with bilateral ureterolysis. The shape and function of the left kidney and ureter have returned to normal after the operation as shown by i.v. pyelograms. A short survey of the literature on this subject is given and a number of diagnostic aspects are discussed. (11 references.)
One case is reported and another discussed of bilateral ureteral obstruction associated with abdominal aortic aneurysms. Ureterolysis was performed without resection of the aneurysm, which is less likely to rupture because of its encasement in the dense retroperitoneal fibrotic process.
The organism Campylobacter fetus exhibits a peculiar propensity to infect vascular endothelium. Campylobacter endocarditis and septic thrombophlebitis have already been seen, as has the secondary infection of a femoral artery aneurysm. However, until now, diagnoses of Campylobacter infections in abdominal aortic aneurysms have only been made at autopsy. One additional fatal case has been documented by the Centers for Disease Control, Atlanta, but the case report has not yet been published. This article demonstrates that inflammatory variant abdominal aortic aneurysms can be culture-positive - a fact hitherto unrecognized, although many physicians have tried to grow organisms from aneurysm cultures and that Campylobacter aortic infection can be successfully treated by a one-stage surgical repair combined with administration of antibiotics.
Eleven of 157 patients undergoing surgery for abdominal aortic aneurysm, with features of both aneurysm and periaortic retroperitoneal fibrosis, are presented. The clinical details, implications and management are reported. The possibility that this association may present with differing relative severity of these two conditions is discussed. aortic replacement is advocated as the treatment of choice because the risk of rupture still exists and this procedure seems to halt, or even reverse, the inflammatory process. Synchronous ureterolysis is reasonably safe and can be undertaken if obstruction is present. Steroids represent an alternative option, where aortic replacement is too hazardous.
Nine operatively treated patients with abdominal aortic aneurysm and associated perianeurysmal fibrosis are reported. The fibrotic reaction closely corresponded to the extent of the aneurysmal disease. In four patients only the periaortic tissue was involved, whereas in the other five there was also involvement of the tissue surrounding the inferior vena cava, the duodenum and one or both ureters. A tentative preoperative diagnosis of perianeurysmal fibrosis was made in three patients and in one of them this was confirmed at computer tomography. In view of the similarity in clinical and microscopic appearance it is suggested that "perianeurysmal fibrosis", "inflammatory aneurysms" and retroperitoneal fibrosis" associated with abdominal aortic aneurysms might represent the same disease or different stages of it.
A 69-year-old woman with an enlarging ascending aortic aneurysm is presented. At operation, the patient was noted to have extensive peri-aneurysmal fibrosis and inflammation with a 1 cm thick aneurysm wall. Pathologic examination was consistent with inflammatory aneurysm. Inflammatory aneurysms of the thoracic aorta are uncommon and this may be the first patient with this process involving the ascending aorta with both operative and pathologic findings.
The high prevalence of abdominal aortic aneurysm (AAA) in men over the age of 65 has led to the establishment of ultrasound screening programmes for this group. The apparent familial tendency towards AAA formation suggests that relatives of aneurysm patients may form another subpopulation in whom screening is appropriate. The first degree relatives of 100 consecutive aneurysm patients were identified. Of 110 relatives over 50 years of age, two were known to have had AAA and ultrasound scans were performed on 74, providing information on aortic size for 76 relatives (69%). No further aortic aneurysms (antero-posterior diameter > or = 4.0 cm) were found on scanning. However, nine relatives were demonstrated to have aortic dilatation (2.5-3.9 cm). Aortic dilatation was observed in 21% of male first degree relatives over 50 years of age, affecting 27% of sons and 17% of brothers. Only 4% of the sisters and none of the daughters were found to have aortic dilatation. The prevalence of aortic enlargement seems to be sufficiently high amongst male first degree relatives of AAA patients over 50 years of age to justify aortic screening.
To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery.
In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group.
Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls.
This study supports the findings that PF tends to regress after repair of the abdominal aortic aneurysm.
The gold standard to clarify an acute pathology of the ascending aorta is transesophageal echocardiography or contrast-enhanced computed tomography. Neither of these methods led to the correct finding in our case of an inflammatory aneurysm of the ascending aorta. Both assessments resulted in the diagnosis of an acute dissection of the ascending aorta.
Retrospective evaluation of postoperative long-term results after surgery of inflammatory aortic aneurysms (IAAA) with computed tomography (CT). Findings in CT were analysed with particular attention to the development of inflammatory tissue adjacent to the aneurysm site.
Of 2101 patients operated on an aortic aneurysm 5.4% (114 patients) presented typical intraoperative features of inflammatory aortic aneurysms. 54 of these 114 patients (47%) were examined via computed tomography pre- and post-operatively. On an average the follow-up-study was performed 2.5 years postoperatively.
All follow-up-studies revealed a correct location of the aortic prostheses. In 85.1% of the cases there was either no or negligible persisting inflammatory tissue with a diameter of less than 2 mm. 10.6% of the patients demonstrated remaining but reduced inflammatory tissue. In 4.3% of the cases the extent of the inflammatory tissue had not changed. Aneurysms of the anastomoses (n = 4), morphologic renal changes (n = 7) and an aorto-enteric fistula were demonstrated by CT as postoperative complications.
In evaluating recurrence of the aneurysm and possible complications as well as the development of the inflammatory tissue, postoperatively performed computed tomography proved a reliable diagnostic method.
Inflammatory abdominal aortic aneurysms may present a challenge to the surgeon, especially because of associated retroperitoneal fibrosis and possible ureteral complications. We present a case of inflammatory abdominal aortic aneurysm with bilateral ureteral entrapment and complete anuria, successfully treated by endovascular grafting and temporary ureteral stenting.
Despite progress in the technical approach to aneurysms, inflammatory aortic aneurysms (IAA) in particular present the surgical team with a unique challenge. This retrospective study investigates immediate and late results after surgical treatment of IAA.
Fifteen cases of IAA among 520 aneurysmectomies of the abdominal aorta were operated during the period 1986-1995. All the patients were males of a mean age of 66 years. Diagnosis was established on preoperative CT-Scan, gross appearance at surgery and histologically. CT scanning could detect the IAA in 13 of 15 cases. In 2 cases MRI was diagnostic. Surgical treatment using the inlay method, constitutes the method of choice due to restricted dissection, as it reduces the possibility of iatrogenic injuries.
None of the patients died during the first 30 postoperative days. One patient died at the age of 78, 40 days after the operative procedure, due to a cerebral episode. Four to 120 months later 3 patients had also died from cause unrelated to the operation and one more patient was lost on follow-up. The remaining 10 patients were free of symptoms without any progression of the fibrotic process in the CT scanning. We observed a total regression in 7 and partial regression in 3 patients without detecting any inflammatory findings or renal failure.
IAA's are rare. CT and/or MRI establish the diagnosis preoperatively and contribute to the surgical program with immediate and late results equal to those found in arteriosclerotic aneurysms of the abdominal aorta.
We report a successful resection of an inflammatory aneurysm following treatment with steroids in a 23-year-old man. Suffering from fever and severe lumbago, he was admitted to our hospital. An ultrasound and computed tomography of the abdomen revealed an infrarenal abdominal aortic aneurysm surrounded by dense perianeurysmal fibrous tissue. We diagnosed it as an inflammatory abdominal aortic aneurysm based on a symptomatic inflammatory reaction and the findings of ultrasound and computed tomography. Since the aneurysmal wall strongly adhered to the surrounding tissues and surgery was ruled out when it proved impossible to expose the vessels sufficiently to obtain vascular control, steroid therapy was started to control fever and severe lumbago. Five months later, we undertook surgery. Our conclusion is that steroid therapy was very effective against a young patient with inflammatory abdominal aortic aneurysm.